central nervous system
home health care

Diagnosis: weakness/cerebrovascular accident (CVA)
treatment: home health care
The insurer denied Additional Personal Care Services Level 2 (beyond 56 hours per week). The health plan's determination is overturned.

The patient is a female with past medical history of cerebrovascular accident (CVA) and resultant right-sided weakness, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), morbid obesity, bipolar disorder, schizophrenia, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, opioid dependence with methadone treatment, anemia, and urinary incontinence who had a universal assessment performed assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, stairs, shopping, bathing, and dressing lower body while extensive assistance with tasks of managing finances, managing medication, phone use, transportation, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at limited assistance with tasks of bed mobility and eating.

Additional Personal Care Services Level 2 (beyond 56 hours per week) are medically necessary for this patient.
There is documentation from the patient's medical providers of medical necessity of increased PCA (personal care assistant) services. The patient has assistance needs with all activities of daily living (ADL) / Instrumental activities of daily living (IADL). Specifically, the patient requires extensive assistance with walking, locomotion, and transfer toilet while maximum assistance with task of toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet the patient's care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The plan incorrectly assumed the patient has informal help outside of the currently assigned PCA service hours. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services Level 2 (beyond 56 hours per week) are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.